Jessica Alexander
Brandon
Summary
Developed critical thinking and analytical skills in high-volume insurance environment, seamlessly interpreting complex data and resolving issues. Proven track record of driving efficiency and accuracy in claims processing while collaborating with cross-functional teams. Seeking to transition into new field where these transferrable skills can contribute to operational success.
Overview
19
19
years of professional experience
Work History
Claims Analyst II, Auditor
NTT Data
11.2019 - 01.2025
- Understand the application of benefits, COB, Fee schedules, and CMS to provide accurate pricing on claims
- Managed high-volume caseloads 70cph, prioritizing tasks to ensure timely completion of all claims with a focus on high-dollar claims
- Maintained compliance with industry regulations and company policies while managing sensitive client information and claims records
- Conducted root cause analyses to identify underlying issues and provide actionable recommendations for resolution
Configuration Analyst/Claims Analyst II
Healthscope Benefits
07.2018 - 08.2019
- Improved configuration processes by streamlining workflows and implementing automation tools
- Provider data maintenance
- Apply policies and procedures to confirm that the claim meets the criteria for payment as indicated in contractual guidelines for new day claims [Medical, Dental & Vision]
- Process facility and provider claims while adhering to CMS guidelines, HIPAA, and contractual agreements
- Skilled use of Health Axis CRT systems and applications for claims adjudication and research of provider, member and utilization management data
Claims Analyst II
NLB,Cognizant Wellcare
07.2017 - 06.2018
- Accurately evaluate and adjudicate Professional and Institutional claims in a timely
- Communicate effectively with manager regarding trends in pricing or coding errors
- Meeting daily & monthly production using Facets 4.0
- Managed high-volume caseloads, prioritizing tasks to ensure timely completion of all claims
- Demonstrated a high level of accuracy and attention to detail in reviewing claim documentation for approval or denial decisions
Claims Analyst II
Anthem Inc. (Previously Amerigroup)
01.2015 - 05.2017
- Responsible for processing Professional/Institutional claims both new day and corrected claims
- Research and analyzes claim issues while maintaining daily & weekly production goals of 97% and 98% quality
- Managed high-volume caseloads for optimal productivity while maintaining strict attention to detail
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, procedures, and HIPAA regulations
- Assisting on special projects with the Care Coordinator Department: Initial Intake for new patients, update patient treatment plan while also connecting them with the appropriate health care provider
- Researched claims and incident information to deliver solutions and resolve problems
Recovery Resolution Analyst II
Amerigroup Corporation
01.2013 - 12.2014
- Research, critical thinking & resolve overpaid claims
- Respond to provider correspondence regarding payment recovery via phone call/letter
- Assist in projects researching payments in archived claims, to prevent overpayments
- Adhere to company HIPPA regulations and CMS guidelines
- Document business operations while updating processing instructions to ensure data accuracy when processing
- Streamlined resolution processes for increased efficiency and quicker response times to customer inquiries
Credentialing (2yrs)/ Configuration Analyst (2yrs)
Freedom Health Plans
09.2008 - 10.2012
- Responsibilities consisted of credentialing/re-credentialing Medicare/Medicaid members for the following POS
- Maintain weekly standards such as production, quality & financial goals
- Abide by CMS policy and regulations while reviewing & researching each application
- Collaborated with healthcare providers to gather necessary information for accurate credentialing decisions
- Complete and access CAQH, DEA, Medical License, Board Certs, Malpractice, CV, NPI, CLIA, OIG & AHCA for file completion
- Assist configuration team with loading Professional and Institutional contracts in the system as well as loading fees (Configuration)
- Conducted root cause analyses of configuration issues, identifying areas for improvement and implementing corrective actions accordingly
- Verify Physician/Facility info to be accurately entered for pricing purposes
- Upload fee schedules from CMS via Drug/Service /DME to ensure accurate pricing
- Responsible for the activities related to system updates, new health plan implementation and conversions
- Responsible for responding back to claims department regarding pricing & rate inquiries within allotted period
- Collaborated with healthcare providers to gather necessary information for accurate credentialing decisions
Provider Service Rep
WellCare
05.2007 - 08.2008
- Resolve provider inquiries about authorization and claim status while lending support to resolve any issues on first call
- Answer customer inquiries regarding eligibility, cover benefits, keep provider database and documentation up to date and accurate
- Assist with the development and implementation of provider training programs
- Assist in reviewing front-end claims for errors such as: overpayment, billing errors & underpayments
- Educated providers on billing procedures, coding guidelines, and reimbursement policies for optimal claim submissions
- Coordinated with internal departments on behalf of providers to ensure timely payment resolution for claims disputes or other financial matters
Claims and Benefit Representative TPA
Health Plan Services (Temp)
01.2007 - 05.2007
- Assist members, providers, brokers & employers with benefit and payment inquiries
- Managed high-volume call center, ensuring prompt and accurate responses to all inquiries related to health benefits
- Maintain weekly goals that consist of production, customer service & quality goal
- Provided timely responses to provider/member inquiries regarding processed claims & benefits while fostering a positive work environment with clear communication channels
- Participated in cross-functional teams to discuss ways to improve overall customer satisfaction across company
Intake Disability Representative
Aetna
03.2006 - 01.2007
- Conduct an initial interview with members via phone which consists of collecting detailed information in a timely manner before forwarding it to the assigned case manager
- Maintained accurate records of all service activities, facilitating smooth communication between clients and technicians
- Send out requested information via email/fax/mail per member's request
- Collaborated closely with nurses assisting with follow ups for patients with LTD/STD care
- Served as a primary point of contact for clients, addressing inquiries, providing updates, and ensuring overall satisfaction with services rendered
Education
High School Diploma -
Vivan Gaither Highschool
Tampa05-1992
Skills
- Analytical
- Interpersonal Skills
- Detailed oriented
- Customer service
- Effective communication
- Active listener
- Initiative-taking
- Medical Terminology
- Adaptability
- Flexible
- Great decision-making skills
- Professional work Ethic
- ICD-9-CM
- ICD-10-CM
- HCPCS
- REV
- CPT Codes
- Data
- Microsoft Office
- Word
- Excel
- PowerPoint
- Processing Systems: Xcelys
- BPMS
- Diamond
- Sidewinder
- Maces
- QNXT
- Facets 40 & 54
- Amysis
- Next Gen
- IKA
- HAX
- HAX 25 & Citrix
Timeline
Claims Analyst II, Auditor
NTT Data
11.2019 - 01.2025
Configuration Analyst/Claims Analyst II
Healthscope Benefits
07.2018 - 08.2019
Claims Analyst II
NLB,Cognizant Wellcare
07.2017 - 06.2018
Claims Analyst II
Anthem Inc. (Previously Amerigroup)
01.2015 - 05.2017
Recovery Resolution Analyst II
Amerigroup Corporation
01.2013 - 12.2014
Credentialing (2yrs)/ Configuration Analyst (2yrs)
Freedom Health Plans
09.2008 - 10.2012
Provider Service Rep
WellCare
05.2007 - 08.2008
Claims and Benefit Representative TPA
Health Plan Services (Temp)
01.2007 - 05.2007
Intake Disability Representative
Aetna
03.2006 - 01.2007
High School Diploma -
Vivan Gaither Highschool
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